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Background: Physicians in prehospital care must be proficient in critical care procedures. Procedure proficiency requires a combination of training, experience and continuous clinical exposure. Most physicians in helicopter emergency medical service (HEMS) in Norway are well-trained and experienced anaesthesiologists, but we know little about their exposure to critical care procedures in the prehospital arena. This knowledge is required to plan clinical training and in-hospital practice to maintain core competences for a HEMS physician., Methods: We collected survey data on critical care procedures performed by physicians at three HEMS bases in Norway for a one-year period. To correct for differences in duty time between physicians, the expected number of procedures performed in a full time engagement at each HEMS base was calculated. Data was analysed using descriptive statistics and expected procedure volume at each base was compared using one-way between group analysis of variance., Results: We received data from 82.7 % of the duty hours in the study period. Physicians at Oslo University Hospital HEMS had the highest volume of procedures in most categories and were expected to perform a majority of the procedures at least once a year. There were significant differences in procedure volume between the bases in 25 procedures., Conclusions: Physicians in Norwegian HEMS perform critical care procedures with variable frequencies. The low procedure volume in some cases and variance between bases indicate the need for a tailored procedure maintenance training and relevant in-hospital clinical practice.

Background: A large number of techniques and devices for cricothyroidotomy have been developed. In this study, the Portex™ Cricothyroidotomy Kit (PCK, Smiths Medical Ltd, Hythe, UK) was compared with the bougie assisted emergency surgical cricothyrotomy technique (BACT)., Methods: Twenty air ambulance anaesthesiologists performed emergency cricothyrotomy on a cadaveric porcine airway model using both PCK and BACT. Baseline performance and performance after the intensive training package were recorded. Success rate, time to secured airway and tracheal damage were the primary endpoints, and confidence rating was a secondary endpoint., Results: During baseline testing, success rates for PCK and BACT were 60% and 95%, respectively. Tracheal injury rate with PCK was 60% while no such injury was found in BACT. A lecture was given and skills were trained until the participants were able to perform five consecutive successful procedures with both techniques. In the post-training test, all participants were successful with either technique. The mean time to successful insertion was reduced by 15.7 seconds (from 36.3 seconds to 20.6 seconds, p< 0.001) for PCK and by 7.8 seconds (from 44.9 seconds to 37.1 seconds, p=0.021) for BACT. In the post-training scenario, securing the airway with PCK was significantly faster than with BACT (p<0.001). Post-training tracheal laceration occurred in six (30%) of the PCK procedures and in none of the BACT procedures (p=0.028)., Conclusions: Testing the base-line PCK skills of prehospital anaesthesiologists revealed low confidence, sub-optimal performance and a very high failure rate. The BACT technique demonstrated a significantly higher success rate and no tracheal damage. In spite of PCK being a significantly faster technique in the post-training test, the anaesthesiologists still reported a higher confidence in BACT. Limitations of the cadaveric porcine airway may have influenced this study because the airway did not challenge the clinicians with realistic tissue bleeding.

Background: An emergency cricothyrotomy is the last-resort in most airway management protocols and is performed when it is not possible to intubate or ventilate a patient. This situation can rapidly prove fatal, making it important to identify the best method to establish a secure airway. We conducted a systematic review to identify whether there exists superiority between available commercial kits versus traditional surgical and needle techniques., Methods: Medline, EMBASE and other databases were searched for pertinent studies. The inclusion criteria included manikin, animal and human studies and there were no restrictions regarding the professional background of the person performing the procedure., Results: In total, 1,405 unique references were identified; 108 full text articles were retrieved; and 24 studies were included in the review. Studies comparing kits with one another or with various surgical and needle techniques were identified. The outcome measures included in this systematic review were success rate and time consumption. The investigators performing the studies had chosen unique combinations of starting and stopping points for time measurements, making comparisons between studies difficult and leading to many conflicting results. No single method was shown to be better than the others, but the size of the studies makes it impossible to draw firm conclusions., Conclusions: The large majority of the studies were too small to demonstrate statistically significant differences, and the limited available evidence was of low or very low quality. That none of the techniques in these studies demonstrated better results than the others does not necessarily indicate that each is equally good, and these conclusions will likely change as new evidence becomes available.

Background: On July 22, 2011, a single perpetrator killed 77 people in a car bomb attack and a shooting spree incident in Norway. This article describes the emergency medical service (EMS) response elicited by the two incidents., Methods: A retrospective and observational study was conducted based on data from the EMS systems involved and the public domain. The study was approved by the Data Protection Official and was defined as a quality improvement project., Results: We describe the timeline and logistics of the EMS response, focusing on alarm, dispatch, initial response, triage and evacuation. The scenes in the Oslo government district and at Utøya island are described separately., Conclusions: Many EMS units were activated and effectively used despite the occurrence of two geographically separate incidents within a short time frame. Important lessons were learned regarding triage and evacuation, patient flow and communication, the use of and need for emergency equipment and the coordination of helicopter EMS.

Background: Alternatives to endotracheal intubation (ETI) are required when access to the cranial end of the patient is restricted. In this study, the success rate and time duration of standard intubation techniques were compared with two different supraglottic devices. Two different manikins were used for the study, and the training effect was studied when the same manikin was repeatedly used., Methods: Twenty anaesthesiologists from the Air Ambulance Department used iGEL™, laryngeal tube LTSII™ and Macintosh laryngoscopes in two scenarios with either unrestricted (scenario A) or restricted (scenario B) access to the cranial end of the manikin. Different manikins were used for ETI and placement of the supraglottic devices. The technique selected by the physicians, the success rates and the times to completion were the primary outcomes measured. A secondary outcome of the study was an evaluation of the learning effect of using the same manikin or device several times., Results: In scenario A, all anaesthesiologists secured an airway using each device within the maximum time limit of 60 seconds. In scenario B, all physicians secured the airway on the first attempt with the supraglottic devices and 16 (80%) successfully performed an ETI with either the Macintosh laryngoscope (n = 13, 65%) or with digital technique (n = 3, 15%). It took significantly longer to perform ETI (mean time 28.0 sec +/- 13.0) than to secure an airway with the supraglottic devices (iGel™: mean 12.3 sec +/- 3.6, LTSII™: mean 10.6 sec +/- 3.2). When comparing the mean time required for the two scenarios for each supraglottic device, there was a reduction in time for scenario B (significant for LTSII™: 12.1 versus 10.6 seconds, p = 0.014). This may be due to a training effect using same manikin and device several times., Conclusions: The amount of time used to secure an airway with supraglottic devices was low for both scenarios, while classic ETI was time consuming and had a low success rate in the simulated restricted access condition. This study also demonstrates that there is a substantial training effect when simulating airway management with airway manikins. This effect must be considered when performing future studies.

Background: The present study was performed to compare blood product consumption and clinical results in consecutive, unselected trauma patients during the first 6 months of year 2002, 2004 and 2007., Methods: Clinical data, blood product consumption, lowest haemoglobin values on day 1-10 after admission, and 30-day mortality were extracted from in-hospital trauma registry and the blood bank data base. The subpopulation of massively transfused patients was identified and analysed separately., Results: The total number of admitted trauma patients increased by 48% from 2002 to 2007, but the clinical data remained essentially unchanged. The mean number of erythrocyte units given day 1-10 decreased insignificantly from 9.4 in 2002 to 6.8 in 2007. New Injury Severity Score (NISS) increased in transfused and massively transfused patients, but not significantly. The number of patients transfused with plasma increased and the mean ratio of erythrocyte to plasma units transfused decreased by about 50%. The mean haemoglobin value in transfused patients on day 2 after admittance was significantly lower in 2007 than in 2002, while that on day 10 was significantly higher in 2007 than in 2002 and 2004. There was no change of 30-day survival from 2002 to 2007., Conclusions: Significant changes of transfusion practice occurred during the past decade, probably as a result of increased focus on haemostasis and more precise criteria for transfusion. Despite a lower consumption of erythrocytes in 2007 than in 2002 and 2004, the mean haemoglobin level of transfused patients was higher on day 10 in 2007. The low number of transfused patients in this material makes evaluation of effect on survival difficult. Larger studies with strict control of all influencing factors are needed.

Introduction: Endotracheal intubation (ETI) has been considered an essential part of pre-hospital advanced life support. Pre-hospital ETI, however, is a complex intervention also for airway specialist like anaesthesiologists working as pre-hospital emergency physicians. We therefore wanted to investigate the quality of pre-hospital airway management by anaesthesiologists in severely traumatised patients and identify possible areas for improvement., Method: We performed a risk assessment according to the predictive Bayesian approach, in a typical anaesthesiologist-manned Norwegian helicopter emergency medical service (HEMS). The main focus of the risk assessment was the event where a patient arrives in the emergency department without ETI despite a pre-hospital indication for it., Results: In the risk assessment, we assigned a high probability (29%) for the event assessed, that a patient arrives without ETI despite a pre-hospital indication. However, several uncertainty factors in the risk assessment were identified related to data quality, indications for use of ETI, patient outcome and need for special training of ETI providers., Conclusion: Our risk assessment indicated a high probability for trauma patients with an indication for pre-hospital ETI not receiving it in the studied HEMS. The uncertainty factors identified in the assessment should be further investigated to better understand the problem assessed and consequences for the patients. Better quality of pre-hospital airway management data could contribute to a reduction of these uncertainties.

A 48-year-old previously healthy woman suffered witnessed cardiac arrest in hospital. She achieved return of spontaneous circulation and was transferred to the intensive care unit. During the following 3 hours, she suffered a cardiac electrical storm with 98 episodes of Torsade de Pointes ventricular tachycardia rapidly degenerating to ventricular fibrillation. She was converted with a total of 99 defibrillations. There was no response to the use of any recommended anti arrhythmic drugs. However, the use of bretylium surprisingly stabilized her heart rhythm and facilitated placing of a temporary pacemaker. Overdrive pacing prevented further arrhythmias and was life saving. A number of beneficial factors may have contributed to the good neurological outcome. Further investigations gave no explanation for her cardiac electrical storm.

Background: Medical emergency motorcycles (MEM) can be used in time-critical conditions like cardiac arrest and multi-traumatized patients in an attempt to reduce the response time. Other potential benefits with MEM are more efficient patient evaluation, reduction of unnecessary EMS car ambulance missions and reduced cost. The potential benefits have been evaluated in this study. The incidence of accidents when operating the vehicle was also of interest., Methods: A prospective study was performed when MEM was introduced as a trial in an urban ambulance service in Norway., Results: A total of 703 MEM missions were registered in the period. The mean emergency driving time was significantly shorter for the MEM than for the ambulance car located at the same station (6 min 24 seconds vs. 6 min 54 seconds). In addition to time-critical conditions, the MEM was used to evaluate patients when the need for emergency medical assistance was uncertain, and this practice lead to a reduced number of unnecessary car ambulance missions. No accidents involving the MEM were registered in the study period. The hourly cost of running the MEM was 29 euro vs. 75 euro for a car ambulance. However, the actual cost benefit is smaller since the weather conditions make it impossible to run a MEM in wintertime., Conclusion: The small reduction in driving time when using a MEM instead of a car ambulance was statistically significant but probably of little clinical importance. The number of unnecessary car ambulance missions was reduced. It was cheaper to operate a MEM than a car ambulance, but the cost-effectiveness was reduced since the MEM could not operate 12 months a year. The lack of accidents may be contributed to the extensive training of the drivers and the fact that the vehicle was operated in daylight only.